ICD-10 Workshop. Financial Disclosure. Quick Guide (if you missed Part I) Tool Box. GEM Files Corcoran Consulting Group (800)

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1 Financial Disclosure ICD-10 Workshop Mary Pat Johnson is a Senior Consultant at Corcoran Consulting Group and acknowledges a financial interest in the subject matter of this presentation. Mary Pat Johnson, COMT, CPC, COE, CPMA Senior Consultant Corcoran Consulting Group Quick Guide (if you missed Part I) Review of the book Read the Introduction Familiarize yourself with the layout Alpha Index, Tabular Index, Tables For Code Selection, start with what you know ICD-9 code and the GEM files Look up term in Alpha Index Instructions will lead to alternate/more specific terms Provide exclusions Confirm in tabular index Again, watch terms and follow instructions Tool Box GEM files ICD-9 to ICD-10 ICD-10 to ICD-9 ICD-10 working files Disease & Injury index (alpha index) Tabular list Drugs table Neoplasms table External causes index GEM Files No decimal point in the codes Three columns Third column describes additional attributes Flags (approximate, no map, combination) Combination entry 1 indicates on (Approximate) 0 indicates off (Direct hit, but verify) GEM File Layout Senile Cataract Example I-9 I-10 + Flags H H H H H H H H H H H in the first position in flag column = approximate

2 How to Use the ICD-10-CM 1. Look up the main term in the Alphabetical Index, scan subterm entries if needed. Review continued lines / additional subterms 2. Note parenthetical terms that help with code selection but do not affect code assignment How to Use the ICD-10-CM (continued) 3. Pay attention to the following index instructions in the Alphabetical Index see, see also, and see category references with and without notes omit code notes due to subterms other instructions found in note boxes, such as code by site 4. Do not code from the Alphabetical Index. Verify the accuracy of the code from the Tabular List How to Use the ICD-10-CM (continued) 5. Read instructional material in Tabular Index, including includes and excludes notes use additional code, code first and code also fourth-, fifth-, sixth- & seventh- digit requirements 6. Consult the ICD-10-CM guidelines for use of specific codes 7. Confirm and assign the correct code 1. Cataract CC: cataracts, OU, slow decrease VA during past 6 mos, trouble reading, glare worsening Dx: Nuclear sclerotic cataracts OD>OS Tx: Schedule phaco IOL OD What is the appropriate ICD-9 code? 1. Cataract Choices in ICD-9 a) Blurred vision b) Senile cataract, unspecified c) Nuclear sclerosis d) Posterior subcapsular 1. Cataract CC: cataracts, OU, slow decrease VA during past 6 mos, trouble reading, glare worsening Dx: Nuclear sclerotic cataracts OD>OS Tx: Schedule phaco IOL OD c) Nuclear Sclerotic Cataract

3 1. Cataract CC: cataracts, OU, slow decrease VA during past 6 mos, trouble reading, glare worsening Dx: Nuclear sclerotic cataracts OD>OS Tx: Schedule phaco IOL OD c) Nuclear Sclerotic Cataract What is the appropriate ICD-10 code? How did you get there? Alpha Index: Search cataract Under cataract search nuclear sclerotic - nuclear - sclerosis see Cataract, senile, nuclear Under Cataract, Senile, Nuclear - - nuclear (sclerosis) H25.1- Take that code to Tabular Index for final digit(s) Code: H25.13 Nuclear sclerotic cataract, OU 2. Secondary Cataract CC: Pseudophake OS, 2 years ago, great difficulty with reading small print Dx: After cataract, OS, obscuring vision Tx: Schedule YAG OS What is the appropriate ICD-9 code? 2. Secondary Cataract - ICD-9 a) Blurred vision b) After cataract, unspecified c) Soemmering s ring d) After cataract, not obscuring vision e) After cataract, obscuring vision 2. Secondary Cataract CC: Pseudophake OS, 2 years ago, great difficulty with reading small print Dx: After cataract, OS, obscuring vision Tx: Schedule YAG OS 2. Secondary Cataract CC: Pseudophake OS, 2 years ago, great difficulty with reading small print Dx: After cataract, OS, obscuring vision Tx: Schedule YAG OS e) After cataract, obscuring vision e) After cataract, obscuring vision What is the appropriate ICD-10 code?

4 3. Cystoid Macular Edema CC: Pseudophake OU, still having trouble reading, not getting better during the past 2 wks Test: OCT OU Dx: CME OU Tx: Intravitreal injection, nonpreserved triamcinolone acetonide, OD 3. Cystoid Macular Edema CC: Pseudophake OU, still having trouble reading, not getting better during the past 2 wks Test: OCT OU Dx: CME OU Tx: Intravitreal injection, nonpreserved triamcinolone acetonide, OD What is the appropriate ICD-9 code(s)? CME 3. Cystoid Macular Edema CC: Pseudophake OU, still having trouble reading, not getting better during the past 2 wks Test: OCT OU Dx: CME OU Tx: Intravitreal injection, nonpreserved triamcinolone acetonide, OD 4. Myopia & Astigmatism CC: Blurry vision, decreased distance vision, glasses no longer adequate Dx: Myopia, OU Regular astigmatism, OU Tx: Rx given What is the appropriate ICD-9 code(s)? 4. Myopia & Astigmatism CC: Blurry vision, decreased distance vision, glasses no longer adequate Dx: Myopia, OU Regular astigmatism, OU Tx: Rx given 4. Myopia & Astigmatism CC: Blurry vision, decreased distance vision, glasses no longer adequate Dx: Myopia, OU Regular astigmatism, OU Tx: Rx given Myopia Astigmatism

5 5. Chronic Open Angle Glaucoma CC: IOP for Chronic Open Angle Glaucoma OU Dx: Uncontrolled COAG OU ; severe VF loss OD, moderate VF loss OS Tx: Schedule Selective Laser Trabeculoplasty (SLT) OD Test: HVF 24-2 What is the appropriate ICD-9 code(s)? 5. Chronic Open Angle Glaucoma a) Ocular hypertension Moderate stage glaucoma Severe stage glaucoma b) Primary open angle glaucoma Severe stage glaucoma c) Open-angle glaucoma, unspecified Moderate stage glaucoma d) Primary open angle glaucoma Moderate stage glaucoma Glaucoma Staging Reminders Not a separate ICD-10 code 365.7x Becomes the 7 th digit on the glaucoma code Address each eye separately even if codes are not defined with laterality 5. Chronic Open Angle Glaucoma CC: IOP for Chronic Open Angle Glaucoma OU Dx: Uncontrolled COAG OU ; severe VF loss OD, moderate VF loss OS Tx: Schedule Selective Laser Trabeculoplasty OD Test: HVF 24-2 b) Primary Open Angle Glaucoma Chronic Simple Glaucoma Severe stage glaucoma 6. Glaucoma Suspect CC: IOP OU per Dr. C IOP: 16 mm Hg OU Disc: Moderate cupping OU Test: OCT, optic nerve, OU Dx: Glaucoma suspect, OU 7. Dry Eye Syndrome CC: Recheck dry eyes, S/P punctal plugs OU Dx: DES stable Tx: Continue artificial tears; RTO 1 yr, PRN if symptoms return What is the appropriate ICD-9 code(s)?

6 7. Dry Eye Syndrome a) Epiphora b) Tear film insufficiency, unspecified c) Chronic inflammation of lacrimal passages d) Other disorders of lacrimal system 7. Dry Eye Syndrome CC: Recheck dry eyes, S/P punctal plugs OU Dx: DES stable Tx: Continue artificial tears; RTO 1 yr, PRN if symptoms return b) Tear Film Insufficiency, unspecified Dry Eye Syndrome 8. Corneal Ulcer CC: corneal ulcer, OD, improved Dx: Central corneal ulcer, almost resolved Tx: Finish meds What is the appropriate ICD-9 code(s)? 8. Corneal Ulcer a) Central corneal ulcer b) Corneal ulcer c) Marginal corneal ulcer d) Corneal scar and opacity 8. Corneal Ulcer CC: corneal ulcer, OD, improved Dx: Central corneal ulcer, almost resolved Tx: Finish meds a) Central corneal ulcer 9. Chalazion CC: Small bump LLL, 3-4 days, increasing pain, redness Dx: Chalazion OS Tx: Warm compresses, meds What is the appropriate ICD-9 code(s)?

7 9. Chalazion a) Abscess of eyelid b) Pain in or around the eye c) Swelling or mass of eye d) Chalazion 9. Chalazion CC: Small bump LLL, 3-4 days, increasing pain, redness Dx: Chalazion LLL Tx: Warm compresses, meds d) Chalazion 10. Diabetes without Retinopathy CC: Recently Dx Diabetes (Type II), needs exam Dx: 1) Diabetes 2) No ocular manifestations (Note: on oral hypoglycemics only) Tx: Letter to PCP/Endocrinologist Recheck 1 yr What is the appropriate ICD-9 code(s)? 10. Diabetes without Retinopathy CC: Recently Dx Diabetes (Type II), needs exam Dx: 1) Diabetes 2) No ocular manifestations (Note: on oral hypoglycemics only) Tx: Letter to PCP/Endocrinologist Recheck 1 yr Diabetes mellitus Diabetic Eye Disease Reminders Uses a combination code Type of diabetes Severity of retinopathy Presence / Absence of macular edema One code tells entire story. Change a digit = change the story No distinction made for controlled diabetes Address each eye separately even if codes are not defined with laterality Consider use of insulin (Z code) 11. Background Diabetic Retinopathy CC: Recently Dx Diabetes (Type II), needs exam Dx: 1) Diabetes (Note: on oral hypoglycemics only) 2) Mild non-proliferative DR, OU Tx: Letter to PCP/Endocrinologist, Control Blood sugars Recheck 1 yr What is the appropriate ICD-9 code(s)?

8 11. Background Diabetic Retinopathy CC: Recently Dx Diabetes (Type II), needs exam Dx: 1) Diabetes (Note: on oral hypoglycemics only) 2) Mild non-proliferative DR, OU Tx: Letter to PCP/Endocrinologist, Control Blood sugars Recheck 1 yr DM w/ mention of complication, not stated as uncontrolled Mild NPDR 12. Age-related Macular Degeneration CC: Decreased vision, difficulty reading Dx: 1) Dry AMD OU 2) Mild cataracts Tx: Rx given, Amsler grid daily Non-exudative macular degeneration Incipient cataract 13. Epiretinal Membrane CC: Increasing distortion, OS X 2 weeks Dx: Epiretinal membrane, OS Tx: Monitor Amsler grid, OU Recheck 1 month, eval progression Macular puckering Preretinal fibrosis 14. Ptosis CC: UL Ptosis OU, causing gradual increased dimness for 6 mos Dx: Mechanical ptosis OU Tx: Schedule ptosis repair OU Test: Bleph VF Mechanical ptosis of eyelid 15. Plaquenil CC: The patient has systemic lupus and is being treated with Plaquenil. Referred for possible maculopathy. Dx: Lupus No evidence of toxic maculopathy, OU Tx: Continued observation Lupus V58.69 Long term (current) use of medication 16. Corneal Graft CC: The patient is 4 weeks status post penetrating keratoplasty, OS. The pt rubbed it and it requires repair. Dx: Complication of corneal graft, OS Tx: Return to OR today for repair using tissue glue, recheck tomorrow Complication due to corneal graft V42.5 Organ or tissue replaced by transplant; cornea

9 17. Floppy Iris Syndrome CC: The patient is taking Flomax. Intraoperative floppy iris syndrome is diagnosed during cataract extraction, OD. It requires mechanical dilation of the pupil. Dx: Intraoperative floppy iris syndrome, OD Tx: Complex cataract surgery, OD c) 1) Nuclear sclerosis 2) Floppy Iris Syndrome Intraoperative Floppy Iris Syndrome 3) E941.3 Sympathomimetics [antiadrenergics] 18. Strabismus Operative Note You are reviewing the op note for a strabismus case done earlier today. You note it was for exotropia, OD - and that two horizontal muscles of the right eye were operated upon. What is your ICD-10 code(s)? 19. Excision of Basal Cell on Lid You are coding the case of a pt who had a 6 mm malignant primary basal cell lesion excised from the left lower lid. Find the code! (Hint Neoplasm chart process like in ICD-9) More help For additional assistance or confidential consultation, please contact us at: (800) or

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11 How To SEARCH For A Code Within ICD 10 CM General guidelines: 1. ALPHABETIC index a place to START 2. TABULAR List is most specific code from here! 3. Report HIGHEST number of characters possible Specific guidelines: 1. Identify reason for visit/encounter a. Diagnoses b. Problems c. Complaints d. Signs and symptoms i. Used for reporting when no related definitive diagnosis is established e. Conditions i. Report those that are an integral part of a disease process 1. Do not use additional codes ii. Conditions that are not an integral part of a disease process 1. Code when present (see below if multiple conditions ) 2. Multiple coding for a single condition a. Required for i. Any condition with a use additional code note b. May be needed for i. Fully describing a condition, such as ii. Late effects iii. Complication codes iv. Obstetric codes 3. Acute and chronic conditions a. If both are present i. Code both ii. Sequence acute code first 560 E. Hospitality Lane Suite 360 San Bernardino, California Telephone: (800) FAX (909)

12 4. Combination code a. Single code to classify either i. Two diagnoses ii. Diagnosis with associated secondary process iii. Diagnosis with associated complication b. Do not use multiple codes if combination code identifies all elements 5. Late effects (sequelae) a. Residual effect after acute phase of injury/illness b. No time limit c. Condition code sequenced first, late effect code sequenced second d. Do not use with acute injury code 6. Impending or threatened condition a. If condition did occur, code as diagnosis b. If condition did not occur, reference impending, threatened i. If subentry terms for impending or threatened are listed: 1. Assign the appropriate code ii. Are not listed: 1. Code existing underlying conditions c. Do not code the impending/threatening condition 7. Reporting same diagnosis code more than once a. Each code may be used once per encounter 8. Laterality a. For codes that can have bilateral sites b. Final character of code indicates laterality (0 or 9, 1, 2, 3) c. If no bilateral code is provided, assign separate codes for right and left sides 9. RARE for Ophthalmology: Documentation for BMI and pressure ulcer stages a. May be based on documentation from clinicians who are not the patient s provider b. Associated diagnosis must be documented by patient s provider c. BMI codes are always secondary diagnoses 560 E. Hospitality Lane Suite 360 San Bernardino, California Telephone: (800) FAX (909)

13 ANSWER KEY

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15 1. Cataract ICD-10 Workshop CC: Cataracts, OD, slow decrease VA during past 6 mos, trouble reading, glare worsening Dx: Nuclear sclerotic cataracts OD>OS Tx: Phaco IOL OD Mary Pat Johnson, COMT, CPC, COE, CPMA Senior Consultant Corcoran Consulting Group H25.13 NS, Cataract, OU 2. Secondary Cataract CC: Pseudophake OS, 2 years ago, great difficulty with reading small print Dx: After cataract, OS, obscuring vision Tx: Schedule YAG OS 3. Cystoid Macular Edema CC: Pseudophake OU, still having trouble reading, not getting better during the past 2 wks Test: OCT OU Dx: CME OU H Other 2 nd cat, OS Z98.42 Cataract extraction status, OS Z96.1 Presence of IOL H CME following cataract surgery, OU 4. Myopia & Astigmatism CC: Blurry vision, decreased distance vision, glasses no longer adequate Dx: Myopia, OU Regular astigmatism, OU Tx: Rx given H52.13 Myopia, OU H Astigmatism, regular, OU 5. Chronic Open Angle Glaucoma CC: IOP for Chronic Open Angle Glaucoma OU Dx: Uncontrolled COAG OU ; severe VF loss OD, moderate VF loss OS Tx: Schedule Selective Laser Trabeculoplasty OD Test: HVF 24-2 H40.11x3 POAG, Severe stage (no laterality) H40.11x2 POAG, Moderate stage (no laterality) H53.40 Unspecified visual field defects

16 6. Glaucoma Suspect CC: IOP OU per Dr. C IOP: 16 mm Hg OU Disc: Moderate cupping OU Test: OCT, optic nerve, OU Dx: Glaucoma suspect, OU H Open angle with borderline findings, low risk (both eyes) 7. Dry Eye Syndrome CC: Recheck dry eyes, S/P punctal plugs OU Dx: DES stable Tx: Continue artificial tears; RTO 1 yr, PRN if symptoms return H Dry Eye Syndrome of bilateral lacrimal glands 8. Corneal Ulcer CC: corneal ulcer, OD, improved Dx: Central corneal ulcer, almost resolved Tx: Finish meds H Central corneal ulcer, OD (Cannot code the improvement) 9. Chalazion CC: Small bump LLL, 3-4 days, increasing pain, redness Dx: Chalazion LLL Tx: Warm compresses, meds H00.15 Chalazion, left lower eyelid Note from Chalazion section header: Excludes2 infected meibomian gland (H00.02-) 10. Diabetes without Retinopathy CC: Recently Dx Diabetes (Type II), needs exam Dx: 1) Diabetes 2) No ocular manifestations (Note: on oral hypoglycemics only) Tx: Letter to PCP/Endocrinologist Recheck 1 yr 11. Background Diabetic Retinopathy CC: Recently Dx Diabetes (Type II), needs exam Dx: 1) Diabetes (Note: on oral hypoglycemics only) 2) Mild non-proliferative DR, OU Tx: Letter to PCP/Endocrinologist, Control Blood sugars Recheck 1 yr E11.9 Type II DM w/o complications E Type II DM with mild NPDR w/o macular edema

17 12. Age-related Macular Degeneration CC: Decreased vision, difficulty reading Dx: 1) Dry AMD OU 2) Mild cataracts Tx: Rx given, Amsler grid daily H35.31 Nonexudative age-related macular degeneration (no laterality) H Other age-related incipient cataract, bilateral 13. Epiretinal Membrane CC: Increasing distortion, OS X 2 weeks Dx: Epiretinal membrane, OS Tx: Monitor Amsler grid, OU Recheck 1 month, eval progression H Puckering of macula, left eye 14. Ptosis CC: UL Ptosis OU, causing gradual increased dimness for 6 mos Dx: Mechanical ptosis OU Tx: Schedule ptosis repair OU Test:Bleph VF H Mechanical ptosis of bilateral eyelids 15. Plaquenil CC: The patient has Systemic lupus and is being treated with plaquenil. Referred for possible maculopathy. Dx: Lupus No evidence of toxic maculopathy, OU Tx: Continued observation M32.9 Systemic lupus erythematosis, unspecified Z Other long term (current) drug therapy CC: The patient is 4 weeks status post penetrating keratoplasty, OS. The pt rubbed it and it requires repair. Dx: Complication of corneal graft, OS Tx: 16. Corneal Graft Return to OR today for repair using tissue glue, recheck tomorrow T85.398A Other mechanical complication of other ocular prosthetic devices, implants, and grafts (initial encounter) 17. Floppy Iris Syndrome CC: The patient is taking Flomax. Intraoperative floppy iris syndrome is diagnosed during cataract extraction, OD. It requires mechanical dilation of the pupil. Dx: Intraoperative floppy iris syndrome, OD Tx: Complex cataract surgery, OD H25.11 Age-related nuclear cataract, right eye (Nuclear sclerosis) T44.6x5A Adverse effect of drug = Flomax H21.81 Floppy iris syndrome

18 18. Strabismus Operative Note You are reviewing the op note for a strabismus case done earlier today. You note it was for exotropia, OD - and that two horizontal muscles of the right eye were operated upon. H Monocular exotropia, right eye 19. Excision of Basal Cell on Lid You are coding the case of a pt who had a 6 mm malignant primary basal cell lesion excised from the left lower lid (including some canthal tissue). C Basal cell carcinoma of skin of left eyelid, including canthus More help For additional assistance or confidential consultation, please contact us at: (800) or